410-2       THE APPLICATION FORM

410-2 A.   WHAT IS AN ACCEPTABLE APPLICATION FORM?

The Gen 50B, Application for Services form, is the initial application form that is used to apply for any public assistance program, except the Heating Assistance Program.  To apply for Heating Assistance, a Heating Assistance Program application must be completed.

The Gen 72, Eligibility Review Form, is the review application form that is used to determine continued eligibility for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.

• If received in the month following the end of the review/recertification period, the Gen 72 Eligibility Review Form form can be used as an initial application form.
   

• If received after the month following the end of the review/recertification period, a Gen 50B Application for Services application form is required.  The Gen 72 Eligibility Review Form form will be accepted to protect the benefit start date, however, it cannot be used as the initial application form.

The Native Family Assistance Program (NFAP) application form is an acceptable application form for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.

The Med 4 specialized application form is also available and its use is encouraged when appropriate.  The Med 4 is used to apply for nursing home, home and community-based services, disabled children living at home (TEFRA) coverage, children applying for or receiving SSI, and APA.

410-2 B.   WHEN IS AN APPLICATION REQUIRED?

1. Upon the individual's first application for a program, even if the individual is already a recipient of another DPA assistance program.
    

2. Upon application from a denied, withdrawn, or closed status, unless the denial or closure was the result of an administrative error.
    

3. Any time the caseworker believes the individual’s circumstances have changed sufficiently to justify conducting a special redetermination of eligibility, including when an office conducts a special review project for all or part of its caseload.

410-2 C.   WHEN IS AN APPLICATION NOT REQUIRED?

1. To reopen a closed case as a result of an individual's timely request for a fair hearing, or to open or reopen a case as the result of a fair hearing decision.
    

2. To reopen a case that had been closed incorrectly.
    

3. To resume benefits after benefits have been suspended.
    

4. To redetermine eligibility after the application is denied for failing to provide verification and the household provides the verification within 30 days from the application filing date.
    

5. To redetermine eligibility after the application is denied for failing to attend an interview and the household contacts the office to reschedule the interview within 30 days from the application filing date.
    

6. When there is a change in “payee”, “in care of” addressee, or mailing address.
    

7. When an aged, blind, or disabled Medicaid recipient who has been living in a Medicaid institution and is ineligible for APA benefits leaves the institution to live in the community, APA benefits may be started without a new application.  A caseworker may require a special review if he or she considers it necessary.
    

8. When an SSI recipient who receives Medicaid but not APA benefits because of being under the age of 18 reaches the age of 18.  A special review application may be required if a caseworker considers it necessary.

410-2 D.   WHAT IS AN IDENTIFIABLE APPLICATION?

An identifiable application is an acceptable application form containing the applicant’s name, address, and signature (or witnessed mark) of the individual seeking assistance or of the individual's authorized representative.  Each DPA office must accept and date the identifiable application when it is presented.

An individual who contacts a DPA office and who shows interest in the program or a desire to apply shall be advised of his or her right to submit an identifiable application on the date of the contact in order to establish the benefit start date.  The individual may file an identifiable application on an acceptable application form, as described at manual section 410-2A.

410-2 E.   WHO CAN SIGN THE APPLICATION FORM?

• An adult household member
   

• An authorized representative
   

• An individual who has legal authority to act on the applicant’s behalf (i.e., Office of Public Advocacy, legal guardian)
   

• An individual with appropriate power of attorney
   

• A responsible person, if the individual filing the application is incapable of applying and of appointing an authorized representative in writing.

The signer must certify, under penalty of perjury, the truth of the information contained in the application.

Any individual has a right to apply for APA and can sign an application.  The proper individual to sign an APA application is the applying adult.  If both members of a married couple wish to apply, they may do so on a single application form if both spouses sign the form.  If the applying adult is incompetent or incapacitated, or wishes to appoint an authorized representative, a responsible individual acting on the individual's behalf may apply for him or her.

410-2 F.   WHO CAN BE AN AUTHORIZED REPRESENTATIVE?

A responsible adult, 18 years or older, may be designated by the applicant in writing as authorized representative.  If the applicant is illiterate, his/her mark must be witnessed by two individuals who must each sign their names and date the document.  No special form is required.

Authorized representatives may sign the application and act on behalf of a household.  A household member should prepare or review the application, if possible, even though the authorized representative will be filing the application and/or attending the interview.

410-2 G.   COMPLETING THE APPLICATION FORM

In addition to making an identifiable application and having it signed by an eligible individual, the applicant must answer all of the questions on the application form.

If the individual requests help in completing the application form, the caseworker will offer assistance.

If the application form is not completed, the caseworker will allow the household an opportunity to complete the form.  In this case, written notification will be sent to the household listing the items that need to be completed.  See manual section 410-5C, Pending the Application.